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  • 1. VARICOCELE UPDATE BY KHALID M.GHARIB Lecturer Of Dermatology And Venereology Zagazig University

2. 2 KHALID M. GHARIBDefinition Bilateral valve disease affecting pampiniform plexus ( which drain from testis, epidydmis and some retroperitoneal collateral ) Clinical varicocele is defined as the presence of distension of the intrascrotal veins of the plexus pampiniformis, which is either a visible bulging of the scrotal skin, or easily palpable, or palpable during Valsalva manoeuvre only. Subclinical varicocele cannot be palpated, but is detected by means of technical investigations. 3. 3 KHALID M. GHARIB 15 % affected by varicocele But about 1/3 of infertile men have varicocele common on left side 75-90 % bilateral varicocele occurred in 10% Unilateral right varicocele is rare. 4. 4 KHALID M. GHARIB 5. 5 KHALID M. GHARIBVaricoceles occur more commonly at the left side ? WHY ?? 6. 6 KHALID M. GHARIB 1-Lt. internal spermatic vein join at right angle with Lt. renal vein. 2-Lt. internal spermatic vein is 5-10 cm longer than Rt. (REMEMBER). 3- incompetence or absence of valves more common in Lt. ( 40%) than Rt. ( 23%) internal spermatic vein. 4- compression of Lt. renal vein between aorta and superior mesentric artery ( nut craker phenomenon) 7. 7 KHALID M. GHARIBAETIOLOGY AND PATHOGENESIS 1- Hydrostatic Venous Pressure In Spermatic Vein: Lead to stagnation of blood ? How? Pressure = height * denisty Every 1 cm = 0.77 mm Hg Lt . Spermatic vein height =40 cm Rt. Spermatic vein height = 35 cm So, Lt. = 40* 0.77= 30 mm Hg Rt. =35 * 0.77 = 27 mm Hg In arteriolar end pressure = 18 mmHg Lead to stagnation of blood tissue hypoxiarelease of ROS 8. 8 KHALID M. GHARIBCONT. 2- ROS: Reactive Oxygen Species source? Abnormal sperm with cytoplasmic droplet. germ cells premature sloughing. peroxidase positive leucocyte. Lead to : lipid peroxidation of plasma membrane DNA damage( so, preferring IVF over ICSI .WHY? ) 9. 9 KHALID M. GHARIB 10. 10 KHALID M. GHARIBCONT. 3- METABOLIC THEORY: Throttenig of artery anatomical variation theory 4-Hyperthermia 5-Endocrinal theory: leydig cell dysfunction 6- Immunological theory: damage to Bl. Test. barrier 7-Epidydamal theory : ischemia, impaired sperm maturation 8- Apoptosis : by heavy metals detected in seminal plasma of varicocele. 9- Geneticdefect of the testis: in primary infertility 11. 11 KHALID M. GHARIBDIAGNOSIS OF VARICOCELE Symptoms: 3 Male infrtility Dregging pain Erectile dysfunction?? Signs: Inspection:III Palpation: diameter of vein >2 mm Reflux: In standing position wthout valsalva: II degree In standing position with valsalva : I degree Dont detect the reflux : subclinical varicocele 12. 12 KHALID M. GHARIBVaricocele and erectile dysfunction On sex practice ) 1- pelvic venopathy syndrome: congenital valve disease in pelvic region lead to 5: VaricoceleVaricose VeinCavernosal Venous LeakageChronic ProstatitisHaemorrhoides 13. 13 KHALID M. GHARIB 2- middle age male with varicocele affecting: seminefrous tubules -> premature germ cells sloughing Leydig cells -> decrease androgen So, lead to premature male climacteric ( andropause) 14. 14 KHALID M. GHARIB 15. 15 KHALID M. GHARIBVaricoceles are graded into: Grade III: When the distended venous plexus bulges visibly through the scrotal skin and is easily palpable. Grade II: When the intrascrotal venous distension is easily palpable but not visible. Grade I: When there is no visible or palpable distension except when the man performs the Valsalva manoeuvre. Subclinical: Where there is no clinical varicocele but an abnormality is present upon scrotal thermography or duplex Doppler ultrasonography 16. 16 KHALID M. GHARIBCan You Detect Right Varicocele Clinically ?WHY? 17. 17 KHALID M. GHARIB#Lt. spermatic vein pressure= 10 mm Hg and ends in Lt. renal vein which pressure = 10 mm Hg. So, any strain can be detected by increase intra abdominal pressure by valsalva m. #BUT in Rt. Side :Rt. Spermatic vein pressure= 10 mm Hg and ends in IVC which pressure = ZERO due to increase intra abdominal pressure not increasing pressure in IVC over Rt. Spermatic vein. #The patient can feel fainting attack before clinicaly detection of Rt. varicocele. 18. 18 KHALID M. GHARIBINVESTIGATIONS 1- Semen analysis: stress pattern? 2-Testicular biopsy ?? 3-Doppler US : more than three veins > 3mm with reflux more than 1 second in valsalva M. 4- venography 5- scrotal thermography : varioscan 19. 19 KHALID M. GHARIBVarioscan? Liquid crystal in thermostrip film Depends on : change in temp. NOT blood flow Used in : 1- detection of varicocele on Rt. Side 2- detection of subclinical cases Normal temp. :32.5 brown Color change every 0.8 What normal temp. for spermatogenesis ? What scrotal temp. ? 20. 20 KHALID M. GHARIBTesticular changes associated with varicocele A- peritubular changes: 1-vascular changes : interstitial arterioles and capillaries are narrowed due to proliferation of endothelial linage. These changes may precede tubular damage 2- leydig cells changes: appear hyperplastic theses changes later on 21. 21 KHALID M. GHARIB B- tubular changes: 1- seminefrous tubules: lead to sloughing of premature germ cells early changes. 2- sertoli cells : Later on degenerative changes 22. 22 KHALID M. GHARIBPrimary Testicular FaliureHypergonadotropic Hypogonadism 23. 23 KHALID M. GHARIBManifestations of varicocele orchropathy 1- increase germ cells in semen due to premature sloupghing HOW TO DIFFRENTATE GERM CELLS FROM ROUND CELLS ? 2- increase number of abnormal forms in semen WHAT THE MOST TYPE OF ABNORMAL FORMS OF SPERMS IN VARICOCELE? Elongated tapered head. 3- OAT pattern in semen analysis: can be found in any stress condition. 24. 24 KHALID M. GHARIBTreatment Men with varicocele but normal semen analysis should not be treated since the male factor is probably not the cause of the infertility. Treatment must interrupt the reflux of blood in the internal spermatic vein and its collaterals, and should be performed bilaterally if reflux is present at both sides. Surgical treatment preferentially uses the supra-inguinal approach 25. 25 KHALID M. GHARIB 26. 26 KHALID M. GHARIB 27. 27 KHALID M. GHARIB 28. 28 KHALID M. GHARIB 29. 29 KHALID M. GHARIB 30. 30 KHALID M. GHARIB 31. 31 KHALID M. GHARIB 32. 32Key MessagesKHALID M. GHARIB1-Reflux of blood in the internal spermatic vein(s) causes testicular and epididymal malfunction as a result of clinically palpable or subclinical varicocele. 2-Varicocele is one of the most common cause of male infertility. 3-The presence of varicocele must be detected in all patients with abnormal semen quality, including azoospermia. 33. 33 KHALID M. GHARIB4-Palpation may fail to detect spermatic venous reflux, and contact thermography is the most accurate diagnostic technique, complemented by duplex Doppler ultrasonography. 5-The natural conception rate after varicocele treatment is three- to fourfold higher than in untreated couples, and is enhanced by a holistic management of both female and male partners. 34. 34 KHALID M. GHARIB